Provider Demographics
NPI:1285061192
Name:ULLOA, JEANNETTE (CRNA)
Entity type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name:ULLOA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:JEANNETTE
Other - Middle Name:
Other - Last Name:ULLOA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3612 LA CUESTA DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-0745
Practice Address - Country:US
Practice Address - Phone:623-628-8318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-09
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY680657367500000X
TX93346367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered